Announcer: :
Coming up on this episode of The Doctor’s Farmacy.
Dr. Cindy Geyer:
We know that two-thirds of people who are cardiometabolically unhealthy actually have sleep apnea, and our perception of how sleep-deprived we are doesn’t always match the reality of what we find when we screen people.
Dr. Mark Hyman:
Welcome to Doctor’s Farmacy. I’m Dr. Mark Hyman. That’s Farmacy with an F, a place for conversations that matter. If you have heart disease or you know someone who’s had heart disease, which is probably everybody listening to this podcast, then you should listen up because this conversation’s going to matter to you. Because we’re going to talk about heart disease, the number one killer in the world, but in a way that might surprise you because a lot of the thinking about heart disease is just plain wrong and a lot of the root causes are being missed, and that’s what we’re going to get into today with none other than Dr. Cindy Guyer, who’s back on our special episode of the Doctor’s Farmacy called House Call.
Dr. Mark Hyman:
Cindy and I have known each other for decades. She and I worked together at Canyon Ranch for years. I hired her to be one of the doctors there, and she ended up taking over the place and became medical director and has been teaching all over the world as one of the leading lights in functional med, integrative medicine. She’s triple board-certified in integrative medicine, functional medicine, I mean, internal medicine, and lifestyle medicine, and she’s recently joined the UltraWellness Center as one of our key staff, and we’re just so happy to have her. She’s got, gosh, a quarter-century of experience in functional medicine, integrative medicine, and she’s one of the smartest docs I know. Cindy, welcome to the Doctor’s Farmacy podcast.
Dr. Cindy Geyer:
Thanks, Mark. Glad to be here.
Dr. Mark Hyman:
Okay. So let’s talk about heart disease because we think we know all about heart disease. Oh, it’s cholesterol, and statins are the cure, and if that doesn’t work, you get a bypass and angioplasty, and if that doesn’t work, you get a heart transplant. Of course, there’s all the normal causes we know, like diabetes and high blood pressure and high cholesterol. But diabetes is a symptom, high cholesterol is a symptom, smoking is a habit, and yet we’re kind of missing the boat, I think, on a lot of the reasons we have heart disease and what we can do about it from a more systems perspective. So let’s talk about just what a big deal this is and how few people actually are meeting the simple behaviors that will prevent heart disease.
Dr. Cindy Geyer:
Yeah. Again, this is another one of those conditions that the debate is, “Well, it’s in my family so I’m doomed to get it,” but we know that 80% of cases of heart disease and diabetes may actually be preventable with diet and lifestyle, and despite that really powerful message, fewer than three percent of the US population is meeting the core four basic characteristics that predict low risk, and it’s a pretty low bar, Mark. It’s-
Dr. Mark Hyman:
And what are those? What are those four things?
Dr. Cindy Geyer:
It’s not smoking, getting the minimum recommended 150 minutes of exercise a week, eating in the top two quintiles of what’s considered a whole foods diet, and having a healthy body fat percentage. Fewer than three percent. I still find that shocking.
Dr. Mark Hyman:
So not too much body fat, eating pretty healthy, a little exercise, and don’t smoke.
Dr. Cindy Geyer:
Yeah. That’s-
Dr. Mark Hyman:
Simple things to do but-
Dr. Cindy Geyer:
We’re not even there yet.
Dr. Mark Hyman:
Three percent?
Dr. Cindy Geyer:
Yeah, three percent.
Dr. Mark Hyman:
What’s really staggering is that not only do the people not meet those habits but that there are some, really, other big factors that we are just so bad at in America. Our whole society is set up to actually cause heart disease.
Dr. Cindy Geyer:
Absolutely.
Dr. Mark Hyman:
What are those things that really are these risk factors, besides cholesterol?
Dr. Cindy Geyer:
Well, of course, it’s inflammation. You and I were working together back at Canyon Ranch when that pivotal study came out. I think it’s been 21 years now.
Dr. Mark Hyman:
I remember that, the New England Journal of Medicine review paper.
Dr. Cindy Geyer:
Yes. Peter Libby and Paul Ridker showing that cardiovascular disease is an inflammatory process, that it’s not just about cholesterol but there’s ongoing inflammation. As you’ve talked about many times on this podcast, inflammation, it’s also a symptom, that it can come from a lot of different places. Because in our paper, our local paper, when that article came out, I don’t know if you remember this, it said, “President Bush’s doctors measured his CRP,” which is the common marker of inflammation, “and they don’t know what to do about it.”
Dr. Mark Hyman:
Right. Right. Right.
Dr. Cindy Geyer:
So it’s one thing to say, “Well, we know inflammation matters.” It’s another one entirely-
Dr. Mark Hyman:
Take aspirin.
Dr. Cindy Geyer:
Take aspirin and the statin, right? But it’s another to say, “Well, what are the root causes of inflammation?”
Dr. Mark Hyman:
Well, that’s true. There’s a lot of them, and some of the things that we don’t typically think of as causing inflammation, infections and allergens and things like that, even toxins and bugs in your gut, but stress causes inflammation.
Dr. Cindy Geyer:
Absolutely.
Dr. Mark Hyman:
Lack of exercise causes inflammation. Bad sleep causes inflammation. Loneliness and isolation cause inflammation. Those are pandemics in America.
Dr. Cindy Geyer:
Yes, unfortunately.
Dr. Mark Hyman:
Chronic stress, loneliness, isolation, bad sleep. I mean, those things are huge in heart disease, and we often miss the boat on helping our patients really deal with those.
Dr. Cindy Geyer:
Right.
Dr. Mark Hyman:
Okay. So a typical person comes in, he’s got a high cholesterol, he or she is at high risk for heart disease, maybe family history. Typical doctor does what work-up and what kind of treatments?
Dr. Cindy Geyer:
So a typical doctor might measure a glucose and an A1C to look at their blood sugar status, and they would do a standard cholesterol profile, which, interestingly enough, calculates your LDL cholesterol, the one we usually think of as being the lousy cholesterol, from a formula, it doesn’t even really measure it, and base most of the decisions on that. If they have symptoms, they might send them to a cardiologist for a stress test.
Dr. Mark Hyman:
If they have chest pain.
Dr. Cindy Geyer:
If they have chest pain, right.
Dr. Mark Hyman:
Or shortness of breath on exercise. It’s already kind of down the road.
Dr. Cindy Geyer:
Right. But most doctors don’t measure a C-reactive protein because, as I mentioned before, it’s like, “Well, what do we do with it?”
Dr. Mark Hyman:
“What do I do with it?”
Dr. Cindy Geyer:
“What do I do with it? Oh, statin and aspirin.” And then they’re probably going to treat them with … If they are pre-diabetic or diabetic, they’re going to give them metformin or medications to lower blood sugar and probably a statin to control the cholesterol. How often do they actually talk to them about those root causes such as diet and stress and sleep? Maybe not.
Dr. Mark Hyman:
Yeah, I was going to say, they’re talking about this polypill as a treatment, which is this combo pill of an aspirin, a statin, and a blood pressure drug.
Dr. Cindy Geyer:
Yes. Yes. Put it in the water. They should put it in the water.
Dr. Mark Hyman:
Just like, “Give it to everybody. It’ll prevent heart disease.” I’m like, “Yeah, okay. Well, why do we have high blood pressure? Why do we have a need for aspirin in inflammation? Why is our cholesterol all screwed up?”
Dr. Cindy Geyer:
Yeah. And it’s really interesting. Believe it or not, there’s a potential behavioral component for patients who go on a statin and their cholesterol’s now normal, it’s good.
Dr. Mark Hyman:
Oh, yeah. “Oh, I can eat my cheeseburger or my fried chicken.”
Dr. Cindy Geyer:
“I can eat my cheeseburger.” Isn’t that interesting, that people change their diet in an unhealthy way when their number’s better?
Dr. Mark Hyman:
Oh, yeah. One of the worst things I ever read was there was a bunch of cardiologists advocating for selling statins over the counter at McDonald’s and fast food restaurants.
Dr. Cindy Geyer:
Oh my gosh.
Dr. Mark Hyman:
I think they do sell even statins over the counter in … It’s like those commercials for the acid blockers, like, “Take some Pepcid because don’t worry, Daddy, you can eat your peppers and sausage. Just take your Pepcid.”
Dr. Cindy Geyer:
I remember this.
Dr. Mark Hyman:
I’m like, “No, don’t eat the peppers and sausage.” So you mentioned they do sort of a cholesterol profile, but there was a hint of a subtext in that sentence where they really weren’t measuring the right thing. We tend to look at things that we’re used to looking at that are easy to test and measure, but one of the things that I think people forget and I think doctors honestly forget is we get trained in this panel of tests. It’s your blood count, your metabolic profile, and your cholesterol, and we measure a few things. Maybe it’s 30, 40 things. Maybe if it’s a super fancy doctor, they’ll measure 100 things. They think they’re checking everything. “Oh, your tests are fine. Everything’s great. You look good.” The truth is that they’re missing a huge amount. There are literally tens of thousands of different molecules in your body all doing things, all the time, every minute, every second, and we ignore most of them. In fact, we may ignore some of those most important ones.
Dr. Mark Hyman:
When it comes to cholesterol, we’ve covered this on the podcast with Dr. Boham and we went really deep into this. We should just do a quick refresher. Because the test that most people get, not the one we get here at the UltraWellness, remember, the test that most people get is an antiquated cholesterol test that doesn’t really tell you a whole lot. I had a patient yesterday who was a classic example of that, right? I’ll tell you about his test in a minute, but tell us about the new kind of testing that we’re doing. It’s not so new because we’ve been doing it for 20 years and the discovery that allowed for the testing was 50 years ago.
Dr. Cindy Geyer:
Yeah. So the focus has been on amount of cholesterol, but we want to know the quality of the cholesterol. So we know, for example, LDL, that’s typically labeled the lousy cholesterol. There’s big fluffy, puffy pattern A LDL cholesterol, which is less easily made into a plaque in the artery, less prone to inflammation and oxidative stress and rupture, so it’s a less risky LDL, whereas somebody could have small, dense pattern B LDL and that’s the really risky LDL. So quality matters, and if you have two people with a calculated LDL of 130, one of them could all have pattern A low-risk LDL and they’re actually fine. Somebody else could have lots of those dense particles that’s not captured by the calculated LDL of 130, so the quality matters.
Dr. Cindy Geyer:
The same is true for HDL. We’ve historically thought of HDL as being the good, healthy cholesterol, but size matters there, too. Small HDL doesn’t seem to be as able to cart out the bad LDL and get rid of it, so we want to know the quality and the size of both the HDL and the LDL, and we want to know what other remnant particles are floating around, like very low density lipoprotein and intermediate density lipoprotein, and those don’t show up on a typical panel.
Dr. Mark Hyman:
Yeah. So, practically, what you see is people come in with what looks like a normal cholesterol. This guy yesterday has early dementia. His cholesterol thing was 160-something.
Dr. Cindy Geyer:
Sounds good.
Dr. Mark Hyman:
Yeah. His LDL was, I think, under 100. His triglycerides weren’t bad. His HDL was 39, which is kind of low. But we looked at his particle number. Even though his LDL, if you’re a regular doctor, you’re like, “Well, that’s great, 160, that’s a great cholesterol,” they missed the boat because his particle number was 1500. It should be under 1000.
Dr. Cindy Geyer:
Wow.
Dr. Mark Hyman:
And his small particles, which should be zero … Or less than 300 you can live with, but anything over that is high. His was 900.
Dr. Cindy Geyer:
Wow.
Dr. Mark Hyman:
And he was a skinny older guy. He was 84 years old and had lost muscle, belly fat, underweight, over-fat, and he was pre-diabetic, and that was driving some of his dementia. But they were like, “Oh, your cholesterol is fine, not an issue.” We also look at a lot of other things besides … And, by the way, in 2021, no one should get the regular cholesterol count. You got to insist from your doctor.
Dr. Cindy Geyer:
I agree with you.
Dr. Mark Hyman:
You can get it from Labcorp, Quest. It’s called NMR, Cardio IQ. It’s so important to do, and I guess the problem is most doctors won’t know what to do with it once they find it. There’s no drug for it, like, “Oh, your LDL’s high. We’ll give you this statin.” It’s like we treat what we can easily test and find, not necessarily what the right thing is. With heart disease, it really is a metabolic issue. They shouldn’t be called cardiologists. They should be called cardio-endo-immunologists, right?
Dr. Cindy Geyer:
Right.
Dr. Mark Hyman:
Because it’s all about the hormones, including insulin and all of the inflammation in the immune system. You mentioned earlier that study by Paul Ridker and Libby, in which was sort of the beginning of the conversation. A lot of the follow-up studies, like the Jupiter trial, they found that if patients had a high LDL but they didn’t have a high CRP, their risk of heart disease was negligible, but if they had a high LDL and a high CRP, that was the problem. So independent of inflammation, it may not be an issue. Also, you can get falsely confused by cholesterol tests. I don’t mean to stereotype people, but it was this cohort of women who were probably in their 70s and 80s who were thin, who were fit. The ladies we’d see at Canyon Ranch would exercise, eat well, don’t smoke, normal blood pressure, no diabetes. Their cholesterol is 300, and their HDL is 100, and their LDL is, I don’t know, maybe 150 or something. They have no small particles, and they have all these large, fluffy things, and they’re in really no risk for heart disease, and they don’t need a statin, right?
Dr. Cindy Geyer:
Right.
Dr. Mark Hyman:
I even asked Peter Libby, who was the chair of cardiology at Harvard, “Do these women need a statin,” and they’re like, “No, they don’t. We don’t have any data that say that they do.” I’m like, “Oh, that’s interesting.” So we have to be really personalized in our approach, and that’s the other feature of functional medicine. It’s not one size fits all, “Everybody gets the polypill, everybody gets the statin and aspirin and blood pressure pill.” No, we have to start to think about what’s the cause. The heart disease is a symptom. It’s a syndrome. There are many, many causes. So let’s talk about this whole idea of metabolic health because we were chatting a little earlier and it’s staggering to me as a physician just how poor our metabolic health is. How healthy are Americans metabolically?
Dr. Cindy Geyer:
Yeah, not very. A recent study was looking at the NHANES data from 2009 to 2016 and-
Dr. Mark Hyman:
These are government surveys.
Dr. Cindy Geyer:
Government survey.
Dr. Mark Hyman:
All of our blood tests and health records and everything, right?
Dr. Cindy Geyer:
And trying to say, “Well, how many people are what we would call metabolically healthy?” For people who may not be familiar with that term, it’s meeting the optimal numbers for a blood pressure less than 120 over 80, HDL levels being in the high range of good range, greater than 40 for men and 50 for women, having triglycerides that are low, having glucose that’s less than 100. They found that 12.12% of Americans-
Dr. Mark Hyman:
12.2% percent.
Dr. Cindy Geyer:
12.2% percent, thank you. 12.2% of Americans were metabolically healthy.
Dr. Mark Hyman:
Which means that almost 88% of Americans are metabolically unhealthy. Since 75% of people are overweight, there’s another 13% there where it’s like, “What’s going on with the skinny people?”
Dr. Cindy Geyer:
Yes. Well, and that’s the interesting piece. Fewer than one-third of so-called normal weight people were metabolically healthy. So that’s another really important message.
Dr. Mark Hyman:
Oh, wait, wait, wait, wait. Wait, wait, wait, wait. Wait. Did you just say that two-thirds of skinny people are metabolically unhealthy and have pre-diabetes-like syndrome?
Dr. Cindy Geyer:
Yes.
Dr. Mark Hyman:
Two-thirds?
Dr. Cindy Geyer:
That’s mind-boggling to me.
Dr. Mark Hyman:
Wow. Okay, so that means that, wow, 95% of Americans are metabolic-
Dr. Cindy Geyer:
No, no, no, it’s still the 88%.
Dr. Mark Hyman:
Oh, the 88% percent. Oh, right, right, because it’s the extra-
Dr. Cindy Geyer:
But they were looking at how strongly it correlated with weight.
Dr. Mark Hyman:
Oh my God, that’s so terrible.
Dr. Cindy Geyer:
So just having a body mass index that’s less than 25 is not a guarantee that you’re metabolically healthy.
Dr. Mark Hyman:
So if you’re a skinny sugar and bagel eater, don’t think it’s fine because you’re skinny is basically the bottom line.
Dr. Cindy Geyer:
Exactly. Exactly. Because foods have other impacts besides just what they do with cholesterol anyway. Foods directly impact the elasticity of the arteries, for example, which is another key player.
Dr. Mark Hyman:
You mean food is more than calories, Cindy?
Dr. Cindy Geyer:
Food is information, Mark.
Dr. Mark Hyman:
There you go.
Dr. Cindy Geyer:
You’ve said that for years. It talks to our genes. It talks to our systems.
Dr. Mark Hyman:
Yeah. Wow. So you’re talking about how the food impacts our metabolic health, and we’re not really good at diagnosing metabolic dysfunction. Okay. One out of two Americans has pre-diabetes or type 2 diabetes, and if you look at this new study, I would argue that nine out of 10 Americans have some degree of pre-diabetes or type 2 diabetes, 90% of Americans. So when you look at that data and you also look at the parallel data that 90% of Americans with pre-diabetes are not diagnosed by their doctor, that’s terrifying, especially because this is a 100% reversible, preventable, treatable condition and it gets worse and worse over time and people just don’t even know they have it and doctors miss it because there’s no pill to take. “Oh, take metformin.” Well, that’s not going to help, right? So what are the kinds of ways that we look at these patients differently? What are the tests that we do? What are the things that we really focus on? When someone comes in with a risk of heart disease and a concern about heart disease, what’s our approach? It’s not just looking at the typical cholesterol and even CRP.
Dr. Cindy Geyer:
Yeah. So we would look at those, of course. We would also want to know, what is somebody’s insulin? Most doctors measure glucose but not insulin. I personally like to look at somebody’s glucose trends over time because if you think about something that’s preventable, you don’t want to wait till they cross that threshold to pre-diabetes or diabetes. So even in the range of so-called normal glucose, Mark, you know this, somebody whose fasting glucose runs less than 85 is in a very different metabolic place than somebody whose fasting glucose is 95 to 99, even though they’re both technically normal. But it’s a spectrum of risk, and the farther along you marked that spectrum, the higher the risk of heart disease and diabetes. So if somebody’s glucose used to be 85 and then it was 91 and now it’s 98, we’re going to talk to that person right off the bat about all the things they need to put into place to prevent it from progressing because they’re already on that spectrum.
Dr. Cindy Geyer:
We also want to know insulin levels, not just a fasting insulin but sometimes the insulin response to food, because the other thing that’s emerged is insulin’s a player, and way before somebody’s blood glucose goes up, they might be pumping out tons of insulin to try to keep it in a good place. Insulin by itself contributes to inflammation and more weight gain around the middle, that visceral adipose tissue. So we want to know their insulin, both fasting and in response to a challenge.
Dr. Mark Hyman:
So wait, wait, wait. Are you saying it’s sugar, not fat, that’s causing heart disease? Is sugar the thing that’s driving the insulin? Because fat doesn’t cause insulin spikes.
Dr. Cindy Geyer:
Fat is a player.
Dr. Mark Hyman:
Fat by itself.
Dr. Cindy Geyer:
Fat by itself is a player, right.
Dr. Mark Hyman:
If you eat fat within the food, it will, but-
Dr. Cindy Geyer:
Yeah.
Dr. Mark Hyman:
Yeah.
Dr. Cindy Geyer:
Yeah. I would say the quality of fat does matter.
Dr. Mark Hyman:
Yeah, of course.
Dr. Cindy Geyer:
We can talk some more about that, but I think fat plays a role with artery elasticity, which is another component of vascular risk.
Dr. Mark Hyman:
Yeah, so fried foods, trans fats, refined oils. Those are nasty, and they [crosstalk 00:19:20]-
Dr. Cindy Geyer:
Absolutely. Absolutely.
Dr. Mark Hyman:
But fat itself, if it’s made from whole food sources, and that’s seeds and avocados and olive oil-
Dr. Cindy Geyer:
Might actually be beneficial.
Dr. Mark Hyman:
… is actually beneficial, yeah. So what you’re talking about is a set of diagnostic tests that are so important but mostly … The particle size number, which nobody’s doing, and the second is not just measuring your blood sugar A1C, which may be perfect and you may be in really bad trouble, but measuring also insulin in response to drinking a couple of Cokes, right? I have a patient, Cindy, that I remember who was at super high risk for heart disease. She looked like the Tasmanian devil. She was just a round apple ball, like this, and her belly was this big thing, and I’m like, “This woman is in big trouble.” She’s inflamed, she’s at high risk of heart disease, high blood pressure, diabetes, and I’m like, “Let’s check her glucose tolerance test with insulin.” This was 20-plus years ago and no one was looking at this. Even today, no one’s looking at this.
Dr. Mark Hyman:
It took 50 years from the time the guy said, “Hey, we should wash our hands before surgery,” for us to wash our hands. McKinley died, President McKinley, because he got shot in the belly and the doctor, [inaudible 00:20:34], he stuck his finger in the wound to check it out without washing his hands, so that’s crazy. It took 50 years from the time the guy said, “Let’s do the stethoscope so we don’t get lice jumping into the doctor’s hair” … They wanted to start using the stethoscope because the doctor used to put their head on the patient. So it takes forever, and we’ve been doing this.
Dr. Mark Hyman:
Anyway, this woman, I did this test, I gave her this drink, and it was the most shocking thing I’d ever seen, and it taught me so much about what we miss in medicine. Her blood sugar was perfect, like 80, and she took the sugar drink, and it was perfect. It never went over 110 after taking the equivalent of two Coca-Colas. You’re like, “Oh, she’s fine.” Her A1C was perfect. Her insulin normally should be under five fasting and under 25 or 30 after a drink. Her insulin was 50 fasting-
Dr. Cindy Geyer:
Wow.
Dr. Mark Hyman:
… and 250 after a drink. So her body was just pumping out insulin, which was making her hungry, slowing her metabolism, putting fat in her belly cells, which were basically inflammation factories, and leading to this perpetual cycle, and she was able to lose 50 pounds like that when we cut out starch and sugar.
Dr. Cindy Geyer:
Wow.
Dr. Mark Hyman:
I just feel like it showed me so much because you can even do a normal glucose tolerance test-
Dr. Cindy Geyer:
If you’re not measuring insulin.
Dr. Mark Hyman:
… and that looks perfect. If you are super hyperinsulinemic, you’re going to miss that patient’s real patient.
Dr. Cindy Geyer:
It’s interesting, Mark, because that scenario is also associated with that cholesterol profile we talked about with the small, dense LDL and low HDL and the sequelae that we usually link to diabetes, fatty liver, peripheral neuropathy, all these other organs that are affected, and it can happen with the high insulins alone before the sugars go up. It’s a metabolic imbalance.
Dr. Mark Hyman:
Yeah. So that’s really the take-home here, is that heart disease is a really a hormonal issue or an insulin resistance and inflammation issue. Unless you address those two things, not with aspirin and statins, which will work to some degree, or metformin, which will work to some degree, but … By the way, high blood pressure, which just goes along with all this stuff … They’re all seen as separate. High blood pressure, cholesterol, diabetes, they’re seen as separate. They’re the same condition. They’re manifestations of the same underlying biology of insulin resistance, and unless you really know how to look at the metabolic pathways in the right way, like we talked about, insulin testing or the cholesterol or the cause of inflammation because, like you said, insulin and resistance is probably the biggest cause, so probably the biggest cause of inflammation is diabetes, pre-diabetes, and the starch and sugar that we eat about a pound of each every day in America. That’s the problem.
Dr. Mark Hyman:
But there are other factors that also contribute that people don’t think so much about, especially cardiologists. So those are the big ones, and, of course, exercise, sleep, stress, all those. We’ve covered those in other podcasts, relationships, connection, community, really important. But there’s some other factors that are a little unusual that we look at in functional medicine that I’d love to dive into that have a big impact. So can you just share some of the other factors that could drive inflammation?
Dr. Cindy Geyer:
Well, yet another example where the gut microbiome seems to play a role. Now that we can do more sophisticated gut testing and look at these microbial patterns, there’s a so-called microbial signature that strongly predicts insulin resistance, diabetes, and cardiovascular disease. A couple of general scenarios you see is there’s a loss of overall microbial diversity in the gut, there’s a loss of a couple of signature species. One’s one of the phyla that produce this signaling molecule called butyrate, and butyrate plays a role as fuel for colon cells to help them replenish and be healthy and it’s also an anti-inflammatory molecule, and another species called Akkermansia muciniphila, and you can tell from the Latin mucin base that it’s a mucus-loving bacteria. So that pattern of low diversity, loss of butyrate, and loss of Akkermansia correlates with loss of integrity of the gut lining, more absorption of unwanted things into the bloodstream, more calories, and more inflammation that in turn exacerbates insulin resistance. So the question is, is it chicken or the egg, because we know that pattern also shows up in response to diet, of course. The standard American diet creates that pattern, right?
Dr. Mark Hyman:
Yeah, I was going to ask you that. Why do you don’t have the good guys and why do you have too many bad guys? It’s because of what we’re eating.
Dr. Cindy Geyer:
It’s because of what we’re eating. That microbiome is influenced by the foods that we feed it. But what’s really fascinating is even our thinking about how medications work. You mentioned metformin earlier, right, and we used to think that metformin helped our cells respond to insulin better, but it also has a microbiome effect. Interesting enough, there was a study that found that people who took metformin, you saw a rebound of microbial diversity, a rebound of Akkermansia, and a rebound of those butyrate species.
Dr. Mark Hyman:
With metformin.
Dr. Cindy Geyer:
With metformin, which I think is fascinating, right? The way we think drugs are working may actually be completely different.
Dr. Mark Hyman:
Oops. We call those side effects, but they’re not-
Dr. Cindy Geyer:
We call those side effects, right? But we also know in functional and integrative medicine that we can achieve the same thing when we encourage people to eat a diverse array of colorful plant-based foods and foods that are really good for rebound of Akkermansia, like polyphenolic foods, berries, deeply-pigmented berries, and greens and garlic and onions-
Dr. Mark Hyman:
Cranberries. [crosstalk 00:26:09], yeah.
Dr. Cindy Geyer:
… and cranberries, right. So, of course, people want a pill, but there are other things that can potentially achieve the same thing.
Dr. Mark Hyman:
Interesting. There’s a new company that came out with an Akkermansia product called Pendulum probiotic.
Dr. Cindy Geyer:
Yes, the Pendulum.
Dr. Mark Hyman:
And it’s fascinating. They’re not saying, “This is a probiotic that’s healthy for your gut.” No, this is a tool to control your blood sugar.
Dr. Cindy Geyer:
Isn’t that funny?
Dr. Mark Hyman:
I think we don’t even think about that, that a lot of insulin resistance can start in the gut. I’ve shared this story recently on a podcast, but I’ll share it again. I had this patient who was diabetic, a very brittle diabetic. He was kind of a Type 1-y, 2-y, but he wasn’t on insulin, but he was all over the place. Put him on a keto diet, sugars dramatically improved, dramatically, going from 250 to 120, 130, better but not where I wanted him. Then one day he called me up, said, “You know, doc, my stomach’s been bothering me. I got the worst gas, and I just feel so bloated and uncomfortable.” I said, “Well, we have to get to the bottom of it. Maybe you have bacterial overgrowth. Maybe you have this, maybe you have that. But in the meantime you’re so miserable. Why don’t you just try some charcoal tablets, see if it gives you some relief of your symptoms?”
Dr. Mark Hyman:
He called me back, says, “I don’t know what happened, doc, but my sugars went to normal. I’m in the 80s now because I took charcoal.” I’m like, “Oh my goodness, this is it. This is these toxic bacteria, and they’re producing toxic molecules, and charcoal is like a sponge for toxins.” So when someone comes in the ER and they swallow a bottle of pills, we make them drink a bottle of charcoal, and they have black teeth. But it works to absorb all the other bacteria toxins, and I was like, “Wow.” Often, the pathway to fixing heart disease might not be through the heart. It might be through the gut-
Dr. Cindy Geyer:
It might be through the gut.
Dr. Mark Hyman:
… or other factors, like toxins. We know the role, for example, of pollution and the particulate matter in a lot of urban areas. There’s a huge correlation with heart disease, right?
Dr. Cindy Geyer:
I think part of that, too, is if we look upstream, even before people form plaques, they can start to have problems with the elasticity of their small arteries, and, in fact, that’s a more typical pattern for how cardiovascular disease shows up in women, that it’s small arteries that have lost their elasticity as opposed to big arteries full of plaque. We can think of that artery, that endothelium, as the canary in the coalmine. They did studies of measuring people’s artery elasticity as they were jogging through urban environments with high air pollution counts, and you could see the arteries lose their elasticity in response to that. They’ve also shown-
Dr. Mark Hyman:
Oh, so all my jogging and running outside in China and Beijing in the middle of winter when the skies were gray probably wasn’t a good idea?
Dr. Cindy Geyer:
Probably wasn’t a good idea. You can even show that those arteries will spasm acutely in response to stress, in response to a Burger King meal, so-
Dr. Mark Hyman:
But not McDonald’s?
Dr. Cindy Geyer:
Let’s say a burger and fries meal.
Dr. Mark Hyman:
Yeah.
Dr. Cindy Geyer:
So if we understand what keeps that endothelium healthy, that can actually clue us into how we keep ourselves cardiometabolically healthy.
Dr. Mark Hyman:
Yeah. It was interesting, also. Heavy metal’s become an interesting phenomenon. There are many heavy metals, especially lead, mercury, arsenic, and so forth … Arsenic’s been linked to diabetes and other things. But the lead story is something that’s fascinating to me because from our perspective in functional medicine, it’s relatively easy to diagnose and treat, but it’s been mostly ignored. If you look at the American Journal of Cardiology, they’ve put out major papers that show that, for example, if your lead level is over two, which is considered, quote, normal, which is about 40% of the population has a lead level over two, which is a lot of people-
Dr. Cindy Geyer:
That’s a lot of people.
Dr. Mark Hyman:
… that the risk of having a heart attack or stroke or dying was far greater than if your cholesterol was abnormal.
Dr. Cindy Geyer:
Wow.
Dr. Mark Hyman:
And yet what doctor’s checking your lead levels or checking your body burden of lead or chelating you as a treatment for heart disease? I think it was called the TACT trial, which was a 30 million dollar randomized control trial of chelation therapy using EDTA, which chelates lead, actually was effective in heart disease. Yet it doesn’t matter what the research shows because we don’t have research evidence-based medicine, we have reimbursement-based medicine. We get paid for doing angioplasties, not chelation, so that’s what keeps getting done, even though the data is there, which is kind of amazing. This was an NIH government study showing that it worked. I was like, “Okay, well, this is very slow to pick up.” But we see this. I think the take-home here is that if you have heart disease, don’t just assume it’s high blood pressure, smoking, cholesterol, diabetes. It could be a lot of other factors. It could be your gut microbiome. It could be nutritional deficiencies. It could be environmental toxins along with lack of sleep and stress and so forth.
Dr. Cindy Geyer:
And, Mark, you know my passion about sleep. I would put a sleep study very high on the radar for anybody who’s got cardiometabolic imbalances because we know that two-thirds of people who are cardiometabolically unhealthy actually have sleep apnea, and our perception of how sleep-deprived we are doesn’t always match the reality of what we find when we screen people.
Dr. Mark Hyman:
I had this guy. I remember him. He was a lawyer, came to Canyon Ranch years ago, 50-plus pounds overweight, desperate to get healthy. He was trying to exercise, eat better, doing everything, nothing was working. So I’m like, “Tell me about your life.” He says, “Well, I’m a lawyer. I work really hard, a lot of hours, and I work at a stand-up desk.” I’m like, “Oh, that’s great.” I said, “Why do you work at a stand-up desk?” This was before people were working at a stand-up desk. He says, “Well, if I sit down, I fall asleep.” I’m like, “Oh, no. You probably have sleep apnea.”
Dr. Mark Hyman:
We did a sleep study, and he had sleep apnea for sure. We got him on a CPAP machine. He lost 50 pounds and reversed his pre-diabetes, his cholesterol, obviously, his weight, blood pressure. Most people don’t realize that it’s a bidirectional thing, so if you’re overweight, it can cause sleep apnea, but if you have sleep apnea, it can cause you to gain weight, and it’s very hard to lose weight. He was able to lose 50 pounds just by getting on a sleep program with a sleep machine that helped him sleep. I was like, “Wow, this is interesting.”
Dr. Cindy Geyer:
We’ve had many people like that.
Dr. Mark Hyman:
Yeah. Honestly, Sandy, I don’t know about you, but I’ve learned way more from my patients than I ever learned in medical school.
Dr. Cindy Geyer:
Absolutely. Absolutely.
Dr. Mark Hyman:
The challenge in being a doctor is you get trained in this paradigm and it’s taught to you as if this is a monolithic truth, like this is a table and that’s all this is and there’s no questioning that this is a table, right? But the truth is we are just learning so much about the body and all of our old ideas are breaking apart. But, unfortunately, people really aren’t accessing them, and it just breaks my heart to see how slow medicine is to adopt the emerging science that we’re talking about, whether it’s around checking for lead or insulin resistance. Insulin resistance is not even a controversial thing. That’s not like heavy metal in the microbiome, which seems weird. Insulin resistance is a well-described known phenomena. It’s just doctors clinically are kind of clueless because the treatments are going to be primarily lifestyle interventions. There’s no drug, “Oh, your cholesterol’s high, I’ll give you statin. You’re insulin resistant, what do I do? Oh, give you metformin.” But that’s not the answer.
Dr. Cindy Geyer:
Or even think of the terminology of borderline blood sugar.
Dr. Mark Hyman:
Oh, yeah. I hate that.
Dr. Cindy Geyer:
Yeah, I do, too.
Dr. Mark Hyman:
Oh my God. It reminds me of this story. It’s this patient whose blood sugar is 120, high, 118, high. 126 is diabetes. I’m like, “So have you seen your doctor about your blood sugar because it’s kind of high?” He’s like, “Well, yeah.” I’m like, “Oh, great. And what did your doctor say?” He says, “Well, he said we’re going to watch it.” I said, “Watch for what?” He said, “Well, watch it until it gets to be in the diabetic range and then he’s going to give me medication.” I’m like, “No.” It’s so terrible. So tell us about a patient of yours, Cindy, that you had, a woman, a post-menopause woman, who really struggled and you helped with this kind of a functional medicine approach.
Dr. Cindy Geyer:
Yeah, this was really interesting because this drove the point home that you can’t rely on body mass index or weight to predict somebody’s risk. Now, she had a strong family history of heart disease, but she came in and I did her cholesterol profile, the advanced one that we talked about, and I was blown away because she was not overweight, she did not have high blood pressure. Her triglycerides were 600. That is through the roof.
Dr. Mark Hyman:
Normal is less than 70. Over 100, I start to worry.
Dr. Cindy Geyer:
Yeah. She had a lot of the small, dense LDL particles. I’m like, “This doesn’t fit with the person in front of me.” But when you measured her waist-hip ratio, it was elevated, so she wasn’t overweight but she had just a little bit extra here.
Dr. Mark Hyman:
Belly fat.
Dr. Cindy Geyer:
Belly fat. We actually did a body composition on her and confirmed that she had some visceral adipose tissue.
Dr. Mark Hyman:
Okay, wait, wait. What’s a body composition? That sounds interesting.
Dr. Cindy Geyer:
So it’s a DEXA scan. It’s the same kind of technology you use to do a bone density, but you can actually do it for a body composition, and it tells you your muscle mass, your fat free mass, and it tells you how much deep belly fat, whether you have fat under your skin or deep in the belly.
Dr. Mark Hyman:
Yeah, so, basically, it looks at how much body fat but where it is.
Dr. Cindy Geyer:
Where, right. And that’s important because you had mentioned your patient with the cholesterol of 150 who was skinny. But I bet if you did a DEXA on him, he had very little muscle mass.
Dr. Mark Hyman:
Oh, for sure. For sure.
Dr. Cindy Geyer:
Very little muscle mass, and those are the ones that can fly under the radar.
Dr. Mark Hyman:
For sure.
Dr. Cindy Geyer:
So what was interesting for her is we did find some underlying issues. She turned out to have Hashimoto’s thyroiditis, and she was hypothyroid, so that can affect cholesterol. I said, “Okay, let’s fix the thyroid first.” She was vitamin D deficient, which can affect cholesterol. So we’re working all these other pieces, and the biggest thing for her, interestingly enough, is she really got engaged in fitness. She had a poor fitness level as we measured it with something called a VO2 Max, maximum oxygen-carrying capacity, and she got on an exercise program, and she came back and her cholesterol was much better. Her fitness was much better. She improved her muscle mass. She was still not where we wanted her to be from a cholesterol standpoint, and she still had some elevated inflammation. Her CRP was high.
Dr. Cindy Geyer:
So it’s yet another incidence where, okay, she’s got some bloating, she’s got some digestive issues, so we then did a breath test, and she ended up having small intestinal bacterial overgrowth. So we addressed the small intestinal bacterial overgrowth, and her inflammatory markers got better. Fast forward 10 years, she’s now got great cholesterol, she has maintained her high level of fitness, she’s become passionate about exercise, and she is cardiometabolically healthy.
Dr. Mark Hyman:
Yeah. What was interesting about her story, Cindy, was that you did a lot of the obvious things but you also tweaked a lot of things that played a role that aren’t typically thought of. She was gluten sensitive, so you got her off gluten because that can cause inflammation.
Dr. Cindy Geyer:
Mm-hmm (affirmative). I forgot about that part, too. Yes.
Dr. Mark Hyman:
She was a little bit low thyroid, and that can affect your cholesterol and definitely increase the risk of heart disease for women. A lot of times, the way we look at thyroid is kind of screwed up. We don’t actually look at the full thyroid panel. We under-treat people who are borderline. When you think about what’s normal, the normal ranges are from two to 92, right, basically. I mean, kids, the range is a little different. But let’s say you’re a teenager till you’re 100, that’s the same reference range, and it doesn’t tell you what’s optimal, it tells you what’s normal. If you were a martian and you landed in America, you’d go, “Oh, it’s normal to be overweight.” Because 75% of the people are overweight, so that’s normal.
Dr. Cindy Geyer:
That’s true.
Dr. Mark Hyman:
It’s abnormal to be thin in this country. That doesn’t mean it’s optimal. With thyroid, the same thing. So you probably tweaked that, and then you also helped with her vitamin D deficiency, which is an interesting factor because vitamin D plays a role in inflammation.
Dr. Cindy Geyer:
Absolutely.
Dr. Mark Hyman:
It plays a role in metabolism and insulin resistance and your thyroid function and everything. The way I think about functional medicine, it’s almost like taking your car for a 100,000-mile 100-point check-up. So you’re just tuning things up. Maybe it’s not broken but just a little off. In and of itself, it may not be the thing, but you add all these things together and you tweak everything, and then people can enter a life of energy and vitality in ways that they just typically would not do by just, “Okay, you have a heart disease risk, here’s a statin, I’ll see you later,” or, “Try to eat better, exercise more, good luck with that.” What does that mean? Eat better? I don’t know.
Dr. Cindy Geyer:
Watch your glucose and come in next year.
Dr. Mark Hyman:
Yeah, right. So we also look at other things with heart disease that we typically don’t look at. I guess we also look at the particle number, we look at the CRP, but we look at other things that mark inflammation, like Lp-PLA, and we look at-
Dr. Cindy Geyer:
Myeloperoxidase.
Dr. Mark Hyman:
Yeah, myeloperoxidase, which is [inaudible 00:39:23] oxidative stress or oxidized LDL. We look at … What are there? There’s good cholesterol absorption or increased absorption or production in the liver. So are you an absorber or producer of cholesterol? We can look at particles, HDL, when their classes are good. We look at so many things. You mentioned body composition testing. We can look at metabolic health through stress-testing and cardiovascular fitness, like VO2 Maxes and heart rate variability. So there’s so much that we do. It’s a 360. Sleep studies. When we think about heart disease, we think way bigger than just the cholesterol, high blood pressure, smoking, or diabetes. It’s a very big container. When we do that, the interventions are usually driven through lifestyle and diet.
Dr. Mark Hyman:
So I have a question for you. When we started at Canyon Ranch, we were still back in the food pyramid-y low fat era, right? This was the food pyramid. Eat six to 11 servings of bread, rice, cereal, and pasta. Fat was at the top along with sugar. Where have we come, and what do you think we should be doing? Because a lot of the thinking before was you should be on extremely low fat diets for heart disease, like Caldwell Esselstyn at Cleveland Clinic, he’s recommending not even any avocados, no nuts, this stuff that’s really been shown to be heart-healthy. So what’s your take on that?
Dr. Cindy Geyer:
Yeah. So it’s interesting, Mark. I think you’ve done a tremendous job of just raising the awareness across the world about the importance of nutrition as one of the most important things we can do for our health because it talks to our cells. It talks to our DNA. It’s really information. Fat also provides information. So if we come back to that artery elasticity, we know that certain kinds of fats can actually help us feel satisfied and full but they have benefits with artery elasticity. You mentioned avocados. There was a study a few years ago that found an avocado a day, this high-fat food, lowered LDL cholesterol 20 points. So it’s this paradox, right? Walnuts-
Dr. Mark Hyman:
So forget the apple a day, it’s the avocado a day?
Dr. Cindy Geyer:
It’s the avocado a day, which I like because I love avocados. Nuts and seeds, they have benefits on endothelial function, on artery elasticity. Extra virgin olive oil, rich in polyphenols, is an antioxidant, anti-inflammatory, benefits on the artery elasticity. So I think there’s a range of fats that people can really thrive with, but I do believe for artery elasticity and artery health in particular emphasize the ones from fish, nuts, seeds, avocado, extra virgin olive oil as a primary source of fats. The other thing about most traditional diets throughout the world through eons, they all share in common a foundation of colorful fruits and vegetables and plant-based foods. So I’m less concerned, to be perfectly honest, about the percentage of those macronutrients, the 10%, 20%, 30%, 40%, and more concerned about the quality. I think that really makes the biggest difference.
Dr. Mark Hyman:
Yeah. What’s interesting in the Virta study, which is a company that was developed to treat diabetes and reverse diabetes virtually using a ketogenic diet, which is 70% fat, including saturated fats, that not only do they reverse diabetes in 60%, they got 90-plus percent off insulin, a lot of diabetes drugs, and 100% off the main diabetes drug. Not only do they have an average of 12% weight loss, which is staggering compared to most studies, which five is a heroic weight loss for people, but when they looked at all their cardiometabolic numbers, all these lipid numbers, cholesterol risk, everything got better, and they were eating 70% fat.
Dr. Cindy Geyer:
Wow.
Dr. Mark Hyman:
Now, that’s not to say that if you’re not diabetic, if you’re a thin, healthy athlete, that if you do the same thing, you might get into trouble if you do that. So it’s really about personalization.
Dr. Cindy Geyer:
It is, and it’s interesting that you say that, Mark, because there’s this concept of metabolic flexibility, and I love that idea. Because if you think way back when we were gatherer-hunters, we had to be able to pivot to whatever food sources were available to us. Some days, we might not just … Well, not me personally, but we might just be nuts and seeds and fruits or whatever we could forage, and then we might get some game and gorge on it and then fast for a bit. So this idea that our metabolism when it’s healthy can flex back and forth and handle whatever macronutrient load it’s given, we’ve lost that metabolic flexibility. In essence, insulin resistance is a loss of metabolic flexibility. So I-
Dr. Mark Hyman:
The only reason I exercise so much and eat good is because sometimes I want to do bad things and I feel like I can get away with it. Maybe not. But the occasional ice cream or … I think it’s true, that whole idea of being metabolically flexible and resistant is a key to health, yeah.
Dr. Cindy Geyer:
And if you look at the three things that have the best data for restoring metabolic flexibility, the ketogenic diet’s sort of down the path. It’s really polyphenols, which is interesting. Those are those deeply pigmented foods like berries and pomegranate. Periods of fasting, we didn’t really talk about that, but fasting might also play a role with cardiometabolic health. I just blanked on the other one. Polyphenols, fasting, and exercise.
Dr. Mark Hyman:
Exercise.
Dr. Cindy Geyer:
Yes.
Dr. Mark Hyman:
Yeah. It’s funny, Cindy. We were talking earlier about the polypill, and there was a great paper that was written looking at all the research on food, and it talked about the polymeal, which was essentially wild salmon, berries, chocolate, red wine, and dark green leafy-
Dr. Cindy Geyer:
Dark leafy greens?
Dr. Mark Hyman:
I’m like, “Pretty much sounds like what I eat.”
Dr. Cindy Geyer:
I know.
Dr. Mark Hyman:
Just I don’t have the wine that much, but sometimes. Well, Cindy, this has been such a great conversation. I think we have way more to talk about. I’m looking forward to having you back on the House Call at The Doctor’s Farmacy podcast. If you’ve been listening to this podcast and it helped you and you learned something and you want to share it with your friends with heart disease or who may be at risk, please do. I think it’s important for people to understand this story.
Dr. Mark Hyman:
At the UltraWellness Center here in Lenox, Massachusetts, we take patients from all over the world. We do virtual care. We’ve got a waiting list, so hopefully you can get in. But we’re really working on how to help people, even through virtual support for groups and so on. We’re going to be able to help you. I think you should for sure think about getting these other kinds of tests, if not here then somewhere else. And, of course, subscribe wherever you get your podcasts, leave a comment, and we’d love to hear how you’ve improved your numbers through whatever you’ve done because there’s always something to learn. And, hopefully, we’ll see you next week on The Doctor’s Farmacy.
Announcer:
Hi, everyone. I hope you enjoyed this week’s episode. Just a reminder that this podcast is for educational purposes only. This podcast is not a substitute for professional care by a doctor or other qualified medical professional. This podcast is provided on the understanding that it does not constitute medical or other professional advice or services. If you’re looking for help in your journey, seek out a qualified medical practitioner. If you’re looking for a functional medical practitioner, you can visit ifm.org and search their Find a Practitioner database. It’s important that you have someone in your corner who’s trained, who’s a licensed health care practitioner and can help you make changes, especially when it comes to your health.
